Migraine triggers: Confront or Avoid?
This week, a new client presented to our clinic whose main concern was struggling with frequent, crippling migraine headaches. I realised it’s been a long time since I read any literature in this area…long enough that there might be interesting new recommendations! Professor Paul Martin, an Australian psychologist researcher (Ozzie Ozzie Ozzie! - had to be done) has been arguing for and demonstrating that avoiding migraine and tension headache triggers may paradoxically either sensitise sufferers or reduce their capacity to tolerate these triggers. Whereas traditional CBT approaches to headache management advocated trigger avoidance, Martin has developed a CBT focusing on graded exposure to learning to cope with triggers (Martin et al., 2021). In this week’s study, Casanova and colleagues (2023) report on a 3-month daily prospective daily diary survey of 1125 people who suffer migraines which aimed to see which events acted as “triggers” (increasing probability of attack) and which were “protective” (decreased probability of headache).
The authors investigated 47 events that could precede migraines, including eight emotional states, three sleep parameters, 11 dietary factors, nine environmental/weather events, four physical states, three hormonal factors, missing medication, five other drug use factors, physical activity and travel. Participants entered daily data via an app, and only those who provided data on at least 75% occasions were included (84% starting sample). People who met criteria for chronic migraine were excluded. The study took place internationally although most were from Great Britain and the United States. 88% were female, aged 18-79 (M = 43), working or studying (93%) and regularly menstruating (55%). Most reported high disability (74% MIDAS Grade IV [highest]).
Every event was neither a trigger nor a protective factor for most participants. 18 events more commonly functioned as protectors including: Happiness (25% protective, 0.4% trigger); relaxedness (14.8% protective, 1.3% trigger); waking up refreshed (33.8% protective, 0.4% trigger); quality of sleep (17.9% protective, 1.8% trigger); longer sleep duration (6.7% protective, 3.5% trigger); and physical activity (10.9% protective, 1.2% trigger). 3 events were never protective: tiredness/fatigue (22.4% trigger); eyestrain (23.8% trigger); neck pain (36.4% trigger). 14 events more often functioned as triggers rather than protective factors including: stress (15.7% trigger, 1.1% protective); anxiety (15.6% trigger, 0.6% protective); irritability (13.7% trigger, 1.1% protective); sadness (12.6% trigger, 0.4% protective); angriness (7.6% trigger, 0.8% protective); boredom (4.3% trigger, 1.6% protective); missed meals (7.1% trigger, 0.7% protective); dehydration (7.4% trigger, 0.7% protective); exposure to bright lights (13.2% trigger; 1.1% protective); exposure to loud noises (13.2% trigger; 0.4% protective); exposure to strong odours (8.7% trigger, 0.9% protective); missing medication (other than that for migraines) (1.3% trigger, 0.2% protective); menstruation (13.8% trigger, 0.1% protective), menopause symptoms (7.8% trigger, 3.3% protective). Where events functioned as a trigger for some people and a protective factor for others, no demographic or migraine characteristics predicted which function it would serve.
The authors also explored compliance with four “healthy lifestyle” recommendations and looked at their associations with migraine risk. The proportion of participants who experienced a protective effect was small: regular exercise (4.1%); regular sleep (7-9 hours per night) (7.1%); regular meals (i.e., not skipping meals) (8.2%); adequate hydration (9.1%). Adhering to all four only had a protective effect in 6% participants. The majority demonstrated no associations between lifestyle guideline adherence and migraine risk. However, the authors cautioned against challenging the importance of these lifestyle recommendations as it was not a true experiment and the recommendations have value for general health.
Clinician implications
For people with episodic (not chronic) migraines and tension headaches, don’t recommend that they avoid triggers. Most so-called migraine triggers aren’t statistically associated with migraines and many are more likely to decrease rather than increase risk.
The learning to cope with migraines approach involves identifying migraine triggers and then producing a plan to help the client gradually expose themselves to increasing levels of the trigger (but not high enough to produce migraines). For example, someone who finds tiredness to be a trigger can work on gradually extending their work time before taking a break, or someone who finds heat to be a trigger, can gradually add layers of clothing until they can tolerate higher temperatures (see Martin et al., 2015 for case examples).
Don’t evoke reactance through too much focus on general lifestyle recommendations such as “get regular sleep”, “don’t skip meals”, “exercise regularly” and “stay hydrated”. Obviously, these are all worthwhile behavioural goals and clients who wish to pursue them should be assisted. However, adherence is likely to be low in sufferers of episodic headache and this may be because they are not especially effective with this problem, so don’t create an alliance rupture over them.
For the original article, go to: https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.14451
REFERENCES
Casanova, A., Vives-Mestres, M., Donoghue, S., Mian, A., & Wöber, C. (2023). The role of avoiding known triggers, embracing protectors, and adhering to healthy lifestyle recommendations in migraine prophylaxis: Insights from a prospective cohort of 1125 people with episodic migraine. Headache, 63, 51-61. doi:10.1111/head.14451
Martin, P. R., Callan, M., Kaur, A., & Gregg, K. (2015). Behavioural Management of Headache Triggers: Three Case Examples Illustrating a New Effective Approach (Learning to Cope with Triggers). Behaviour Change, 32(3), 202–208. https://doi.org/10.1017/bec.2015.8
Martin, P.R., Reece, J., MacKenzie, S., Bandarian-Balooch, S., Brunelli, A., & Goadsby, P.J. (2021). Integrating headache trigger management strategies into cognitive-behavioral therapy: a randomized controlled trial. Health Psychology, 40, 674-685.